RESUM ASKEP

PRAKTIK NERS STAGE KEPERAWATAN MEDIKAL BEDAH

STIKES MUHAMMADIYA BANJARMASIN

NAMA MAHASISWA
NPM
TEMPAT PRAKTIK
TANGGAL

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1. IDENTITAS KLIEN
a. Nama klien
b. Umur
c. Jenis kelamin
d. Diagnosis medis
e. Tanggal pengkajian

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PARAF CI

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2. KELUHAN UTAMA
a. Data subjektif
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b. Data objektif
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c. Pengkajian nyeri (PQRST)
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R _______________________________________________________________________
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3. DATA FOKUS PEMERIKSAAN FISIK
a. Inspeksi
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b. Palpasi
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c. Perkusi
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d. Auskultasi
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e. Tanda-tanda vital
Tekanan darah
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Denyut nadi
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Respirasi
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Temperatur
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Saturasi oksigen : _______________________________________________________
4. ANALISA DATA
DATA

ETIOLOGY

MASALAH

5. DIAGNOSA KEPERAWATAN
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a. Tujuan
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b. Kriteria hasil
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6 INTERVENSI KEPERAWATAN
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6. IMPLEMENTASI
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7. EVALUASI
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